Sunday, January 6, 2019
Patient Perceptions of Surgical Decision Making
Qualitative research is frequently used in the social sciences but is rarely encountered in the spine surgery literature. Much has been written about the use of shared decision making to aid patients deciding about whether to undergo spine surgery, though there is scant literature about what the patient experiences during this process. This topic does not lend itself to traditional quantitative methods using patient reported outcomes and requires a qualitative approach. Dr. Andersen and colleagues from Denmark designed a qualitative study to evaluate patient perceptions regarding the decision to undergo lumbar discectomy. They interviewed 14 patients presenting with radiculopathy in the presence of an MRI-confirmed lumbar disk herniation to determine which factors affected their decision-making. Nine of the fourteen also underwent a second interview 1-2 months later. The interviewers asked them open-ended questions about the decision-making process and recorded the discussions. They then coded the patient statements according to themes, and the group arrived at four main themes that they observed across the interviews. The major factors that affected decision-making and how the patients experienced the process were the level of patient information, the effect of accelerated workflows, the power imbalance between clinicians and patients, and the patients' personal experiences with acquaintances who had been treated for a lumbar disk herniation. The investigators found that patients frequently had misinformation prior to meeting with a spine surgeon, and this misinformation affected their decision-making. Patients also reported feeling rushed through the process, which led some to decide to go ahead with surgery without feeling as though they had sufficient time to make the decision. Many patients reported feeling as though they would defer to the recommendation of the surgeon as they saw the surgeon as the expert whose opinion was more important than their personal preferences. Some based their opinion about discectomy on the spine surgery experiences of others they knew, which could be either positive or negative.
The authors have done a very nice job performing a qualitative analysis regarding the patient experience during decision-making around lumbar discectomy. Such studies are not common in the spine literature, and this type of analysis is key to getting at topics such as this. A traditional quantitative analysis using measures of decisional conflict and satisfaction with decision-making would have lost the meaningful information that can only be captured through interviewing. The results of this study are not surprising and are in-line with many studies looking at shared decision-making. The challenging aspect of this type of study is that most of the factors that made decision-making difficult were outside of the control of the clinicians. The misinformation that patients had prior to the spine consultation tended to be from the internet, non-spine clinicians, and other patients. Surgeons are familiar with correcting false information with patients, and this is a difficult, time intensive process. In reading the comments from the patients about power imbalance, it suggests that some patients do not necessarily see this as a problems but simply as the reality of the situation. They view clinicians as experts and seem happy to follow their advice. Many patients felt pressured to make a decision about surgery quickly, though this was indirect and more related to the scheduling process than actual pressure applied by the surgeons. Qualitative research is not well-understood by the spine community (or myself for that matter), and it seems to have a high risk of bias as the researchers determine the themes. This process is clearly shaped by their beliefs, and it is hard to know if the comments determined the themes or if the researchers had preconceived notions about the themes and found comments to support these categories. Despite these limitations, a qualitative design is likely the only way to study this topic. The results suggest that we still have a long way to go to reach truly shared decision making.
Please read Dr. Andersen's article on this topic in the January 15 issue. Does this change how you view the patient experience in deciding about a lumbar discectomy? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor